Palliative wounds are often a challenge to treat. They have the potential to cause tremendous suffering and debilitation, as well as a vastly diminished quality of life. This article discusses palliative wound care approaches and treatment goals for nonhealing wounds at end-of-life.

Sarah Jones, age 76, is a widow who lives alone. Due to a terminal condition, she is now on hospice. She has advanced breast cancer with a fungating malignant tumor. The tumor has broken through her skin and manifests as a malodorous, exuding, necrotic skin ulcer, about 3.5 cm. In diameter, on her medial left breast. These types of wounds rarely heal and often need palliative management. The pungent odor fills her small house. Sarah is embarrassed, depressed, and socially isolated. Her family is distressed and no one wants to visit her. The constant odor makes her nauseous and anorexic. She also has large volumes of uncontrolled serous exudate which stain her clothes and furniture. What can be done to help Sarah?

Palliation is a broad term that focuses on the relief and prevention of suffering in patients whose diseases or conditions are no longer responsive to curative treatment, due to advanced, life-limiting illness. The goal of palliative care is to prevent, manage, and relieve unpleasant symptoms and to promote the best possible quality of life for patients as they near life's end. As the dying process progresses and the patient becomes increasingly weak, wounds can complicate care and threaten the patient's quality of life.

The skin is the largest body organ. Wounds at or near end of life are often challenging to treat and may resist healing, despite meticulous skin care and frequent repositioning. Some palliative wounds are unavoidable due to an underlying disease process. Palliative skin care strategies include stabilizing the wounds that already exist, preventing new wounds, managing unpleasant symptoms, and promoting a dignified and comfortable high-quality end-of-life. Though palliative care is not curative in focus, patients nearing the end of their lives may benefit from the curative aspects of wound care. With severe illness, however, comfort may be more important than preventive or curative measures.

Some wounds in dying individuals, despite the best efforts of clinicians and caregivers, defy healing. Nonhealing wounds at end-of-life are most often directly related to debilitation from advanced chronic conditions and life-threatening illness. The skin is vulnerable to breakdown, with limited ability to heal and regenerate. Factors that contribute to the skin becoming vulnerable, impaired, and dysfunctional at life's end include immobility, decreased intake of food and fluid, diminished perfusion of tissues, impaired synthesis of protein, and overall poor general physical condition. These factors can preclude complete wound healing.

Nonhealing wounds cause tremendous suffering and debilitation to the patient at end-of-life. In cases where complete wound healing is not feasible, treatment involves attacking the symptoms and underlying causes, where possible. The goals should include managing wound exudate, controlling malodor, optimizing function and mobility, preventing infections, and adequately controlling pain and other distressing symptoms.

Wound exudate is often associated with leakage and malodor. It can be controlled by various types of dressings, depending on its volume and viscosity. The surrounding skin also needs to be protected from maceration and excoriation. Chronic wound exudate is corrosive and can readily cause skin irritation. The ideal dressing absorbs excess exudate from the wound and surrounding skin, while keeping the natural wound bed environment adequately moist. For light to moderate exudate, moist wound dressings such as hydrogel, hydrocolloid, or transparent films are warranted. On the other hand, moderate to heavy exudate calls for more absorbent measures: alginate, hydrofiber, or foam dressings or vacuum-assisted wound therapy. Malodor can be one of the most distressing symptoms of palliative wounds. Wound odor can be ameliorated (though often not entirely eliminated) by timely dressing changes, charcoal-activated dressings, treatment for underlying infections, debridement of nonviable tissue, metronidazole, room deodorizers, and placement of a pan with kitty litter under the patient's bed.

The hospice nurse, in collaboration with the entire interdisciplinary hospice team, is developing a plan of care to address the exudate and malodor problem that has caused Sarah such distress. Hopefully, in implementing some of the strategies detailed above, Sarah will find adequate relief from these horrific symptoms.

VickyRN is a certified nurse educator (NLN) and certified gerontology nurse (ANCC). Her research interests include: the special health and social needs of the vulnerable older adult population; registered nurse staffing and resident outcomes in intermediate care nursing facilities; and, innovations in avoiding institutionalization of frail elderly clients by providing long-term care services and supports in the community. She is faculty in a large baccalaureate nursing program in North Carolina.